Long Acting Reversible Contraceptive Referral Letter
Long Acting Reversible Contraceptive (LARC) Referral Letter into Bristol Sexual Health Service (BSHS) from Primary Care
|Patient Details | |Referrer Details | |
|Name | |Referrer Name | |
|Address | |Practice Name | |
| | |Practice Address | |
|Date Of Birth | | | |
|Contact Number | |Contact Number | |
|Contact Permissions | Phone Yes / No |Contact Email | |
| |Text Yes / No | | |
| |Leave Message Yes / No | | |
Please note that due to funding issues we are unable to insert IUS for gynaecological reasons alone eg postmenopausal endometrial protection or heavy menstrual bleeding in a woman who has been sterilised - these patients require gynaecology referral.
Dear colleague, Referral Date
Following a discussion on contraception choices with this patient we are pleased that she has chosen to have a long acting reversible contraceptive fitted:
IUD IUS Implant
Unfortunately we are unable to initiate the method on this occasion due to the following reason:
A) We are not signed up to a Local Authority contract with Public Health to deliver the above LARC method
B) We are contracted to deliver the above LARC method, but there are no professionals currently available trained in this method and my local authority commissioner has been informed1
C) We are contracted to deliver the above LARC method, but patient prefers to be seen at BSHS due to a previous difficult fit
D) Failed removal2 or insertion (please provide further details below)
Details
2 all lost thread referrals for removal must have an ultrasound report included from the last 6 months confirming that the IUS/IUD is in situ. For complex implant removals please state whether the implant was palpable.
E) Medical concerns (please provide any other relevant details below)
Details
Medical History & Current Medication
Please provide details below or attach a printout of recent attendances and medications/allergies.
Is current method lifespan expired? Yes / No
If yes give date
If due to expire give date
We have provided her with the following bridging method of contraception until she has her LARC method fitted:
Condoms
Combined oral contraceptive pill
Progestogen only pill
Please inform the patient that due to increasing demand, there is often a wait of several weeks for complex insertions and/or removals with BSHS
Yours sincerely
1Contact details for local authority commissioners are:
Bristol City Council
Annette Billing, Public Health Principal (Sexual Health)
Annette.Billing@.uk 0117 922 3694
North Somerset Council
Fiona Miles Health Improvement Specialist
Fiona.Miles@n-.uk 01275885576
South Gloucestershire Council
Lottie Lawson, Health & Well Being Partnership Officer (Sexual Health)
Lottie.Lawson@.uk 01454 866195
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Please complete this form as fully as possible. Patients will be contacted by the BSHS Team to arrange an appointment once the referral has been received and triaged.
Please post or fax the form to : Fay Webb (LARC referral administrator)
BSHS, Central Health Clinic,
Tower Hill BS2 0JD
Fax: 0117-925 3400
Any queries telephone Fay Webb: 01173426951
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